Pulmonary-vein isolation for atrial fibrillation in patients with heart failure.
BACKGROUND
Pulmonary-vein isolation is increasingly being used to treat atrial fibrillation in patients with heart failure.


METHODS
In this prospective, multicenter clinical trial, we randomly assigned patients with symptomatic, drug-resistant atrial fibrillation, an ejection fraction of 40% or less, and New York Heart Association class II or III heart failure to undergo either pulmonary-vein isolation or atrioventricular-node ablation with biventricular pacing. All patients completed the Minnesota Living with Heart Failure questionnaire (scores range from 0 to 105, with a higher score indicating a worse quality of life) and underwent echocardiography and a 6-minute walk test (the composite primary end point). Over a 6-month period, patients were monitored for both symptomatic and asymptomatic episodes of atrial fibrillation.


RESULTS
In all, 41 patients underwent pulmonary-vein isolation, and 40 underwent atrioventricular-node ablation with biventricular pacing; none were lost to follow-up at 6 months. The composite primary end point favored the group that underwent pulmonary-vein isolation, with an improved questionnaire score at 6 months (60, vs. 82 in the group that underwent atrioventricular-node ablation with biventricular pacing; P<0.001), a longer 6-minute-walk distance (340 m vs. 297 m, P<0.001), and a higher ejection fraction (35% vs. 28%, P<0.001). In the group that underwent pulmonary-vein isolation, 88% of patients receiving antiarrhythmic drugs and 71% of those not receiving such drugs were free of atrial fibrillation at 6 months. In the group that underwent pulmonary-vein isolation, pulmonary-vein stenosis developed in two patients, pericardial effusion in one, and pulmonary edema in another; in the group that underwent atrioventricular-node ablation with biventricular pacing, lead dislodgment was found in one patient and pneumothorax in another.


CONCLUSIONS
Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation. (ClinicalTrials.gov number, NCT00599976.)
Khan
Mohammed N
MN
Cardiovascular Associates, Elk Grove Village, IL 60007, USA. mnktx@yahoo.com
Jaïs
Pierre
P
Cummings
Jennifer
J
Di Biase
Luigi
L
Sanders
Prashanthan
P
Martin
David O
DO
Kautzner
Josef
J
Hao
Steven
S
Themistoclakis
Sakis
S
Fanelli
Raffaele
R
Potenza
Domenico
D
Massaro
Raimondo
R
Wazni
Oussama
O
Schweikert
Robert
R
Saliba
Walid
W
Wang
Paul
P
Al-Ahmad
Amin
A
Beheiry
Salwa
S
Santarelli
Pietro
P
Starling
Randall C
RC
Dello Russo
Antonio
A
Pelargonio
Gemma
G
Brachmann
Johannes
J
Schibgilla
Volker
V
Bonso
Aldo
A
Casella
Michela
M
Raviele
Antonio
A
Haïssaguerre
Michel
M
Natale
Andrea
A
D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery* / Q000628:therapy; D002304:Cardiac Pacing, Artificial; D017115:Catheter Ablation; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010807:Physical Endurance; D011183:Postoperative Complications; D011667:Pulmonary Veins / Q000601:surgery*; D013318:Stroke Volume
D000889:Anti-Arrhythmia Agents